Chronic hypertension medical therapy blood pressure goals of treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Deputy Editor-In-Chief Robert G. Badgett, M.D.[2]

The 24-hour ambulatory systolic pressure may better mortality than the daytime systolic blood pressure.

Regarding the accuracy of office oscillometric and home blood pressure monitoring compared with ambulatory blood pressure monitoring, a meta-analysis by the Rational Clinical Examination found^[1]:

• Office pressures (presumably attended by medical personnel) has sensitivity and specificity of 51% and 88%
• Home monitoring has sensitivity and specificity of 75% and 76%

Elevated high-sensitivity cardiac troponin T (hscTnT) and N-terminal pro-B-type natriuretic peptide (NTproBNP) levels may help guide treatment.

The decision to treat may be affected by projected longevity of a patient^[2]:

• “for patients 60 years and older with hypertension, intensive BP treatment may be appropriate for some adults with a life expectancy of greater than 3 years
• “but may not be suitable for those with less than 1 year.”

Recommendations for treatment goals from recent clinical practice guidelines are tabulated below. However, treated based on underlying risk rather than a blood pressure target may be more effective. The logic supporting a target of 130/80 mm Hg has been disputed and the Cochrane Collaboration found insufficient evidence to determine a treatment goal for adults or adults over 65 years of age.

If the goal is 130/80, proper measurement includes (distilled from Table 8 of the ACC/AHA guidelines, executive summary):

• having the patient sit quietly for 5 minutes before a reading is taken
• supporting the limb used to measure BP
• ensuring the BP cuff is at heart level
• using the correct cuff size
• for auscultatory readings, deflating the cuff slowly
• the timing of BP measurements in relation to ingestion of the patient’s medication should be standardized
• a single reading is inadequate for clinical decision-making. An average of 2 to 3 BP measurements obtained on 2 to 3 separate occasions will minimize random error and provide a more accurate basis for estimation of BP.

If the above measurement methods are not use, a preliminary study from Kaiser Northern California suggests a target of 140 mm Hg.